The coronavirus disease 2019 (COVID-19) crisis has put extraordinary demands on hospitals and emergency departments (EDs), but outpatient clinicians on the front lines should not be ignored.1 Primary care practices are the tip of the spear in confronting this pandemic. Public officials from the local health department to the White House are advising people to contact their doctor if they are sick or have questions. Although some people are going directly to EDs, the vast majority of calls and visits are coming to primary care.
As COVID-19 spreads across US communities both urban and rural, primary care is the first line of defense to limit the flood of patients to hospitals. Strategies to prevent primary care from being overwhelmed and overrun are urgently needed for 3 reasons. First, primary care teams are intercepting patients of low acuity and diverting them from the ED by fielding questions, triaging patients, and addressing community fears. Second, they are simultaneously treating moderately ill patients, helping them manage symptoms at home and recognize subtle signs of decompensation. As hospitals reach capacity, severely ill patients weaned from ventilators are being discharged home to be managed by community-based primary care and specialty practitioners. Third, primary care physicians (and other outpatient specialists) are stepping in to cover extra hospitalist shifts as inpatient physicians become ill or overwhelmed. If the primary care infrastructure fails,2 much like a collapsing levy, the flood of calls and visits to hospitals and EDs will grow even more overwhelming.
As intensive care units (ICUs) become inundated with patients, primary care is also experiencing volume overload. Accordingly, practices are scrambling to keep patients and staff safe, while facing financial collapse.2 In a perfect world, the federal government would mount an organized response to safeguard the integrity of the primary care system. For example, the UK’s National Health Service (NHS) has a national plan for triaging patients. Public information messages instruct everyone in the country with possible symptoms of COVID-19 to avoid visiting their general practitioner or a hospital and to instead call the NHS111 hotline. The hotline operators field questions and provide instructions, thereby reducing the risk of primary care practices becoming swamped or an entire clinic’s workforce being infected.
Lacking a national plan, individual health care systems have taken matters into their own hands. Most have been consumed with equipping hospitals with reliable screening tests, ventilators, and personal protective equipment; some have created centralized call centers, switched to telehealth visits, or designated separate areas to cohort patients and staff. While these efforts are helpful for individual health care systems, they may be insufficient to alleviate pressures on primary care throughout a region. Community practices have been forced to contrive their own solutions, and the tsunami of patient calls being received leaves them no time to pore over the large volume of documents being produced daily by national and local agencies.
To supplement the meager national response, regional entities could serve as central conduits to support primary care practices across the region and rapidly facilitate bidirectional dissemination of information. Such a model is needed across the US—and the need is urgent.
Academic health centers (AHCs) and other large organizations can leverage their scientific expertise and robust clinical workforce to create this type of primary care extension program, working in close partnership with state and local public health leaders.3,4 Oregon Health & Science University (OHSU) has partnered in this way to implement the centralized COVID-19 Connected Care Center.
This model is being implemented in 3 phases.5 In phase I, a hotline was made available statewide to established OHSU patients, allowing for immediate nursing assessment and facilitation of primary care telemedicine visits. Phase II added a provider hotline for primary care practices throughout the state, providing technical assistance with operations, logistics, and clinical questions. The provider hotline is staffed by medical students, residents, and faculty who update and share information with colleagues in real time (or as close to real time as possible, depending on call volume). This hotline mirrors an existing OHSU specialty consult line, which serves the primary care community in rural and frontier counties. Phase III is slated to expand the patient hotline to the 25% of Oregonians without access to primary care6 and patients of small practices that lack the resources of larger health care systems, offering them nursing advice and video visits, if needed.
A similar statewide resource center could come to the aid of primary care teams in other states, especially states with large and geographically dispersed populations served by independent practices. For states such as Oregon with only 1 large AHC, the state’s AHC could partner with local public health agencies to support statewide efforts to equip primary care practices with real-time answers and a team of clinicians to conduct virtual visits with patients who lack immediate access to primary care. This triage and virtual visit service could also support small primary care practices overwhelmed by volume. These partnerships could rapidly create an extension service, equipping clinicians throughout the state with trusted information that is updated in real time and available via synchronous and asynchronous consults.3 The hotline teams can stay abreast of daily briefings and monitor real-time surveillance data—removing the need for each practice to do their own research and “recreate the same wheel.” An AHC hotline could include health professional (eg, medical, pharmacy, nursing) students, residents, and faculty working remotely.
Some AHCs may need to serve multiple states (eg, University of Washington’s WWAMI network); others could collaborate to serve segments of states or regions. Many AHCs have spent recent weeks converting outpatient clinics into hospitals and operating rooms into ICUs as well as credentialing, training, and mobilizing their entire physician workforce to provide higher levels of care. They should now help to ensure that all people in the US have access to a hotline and virtual visit, if needed, and that all primary care clinicians have timely access to accurate information. This is what primary care patients deserve and the nation requires to serve the growing number of patients with COVID-19.
Corresponding Author: Jennifer E. DeVoe, MD, DPhil, Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Park Rd, Mail Code FM, Portland, OR 97219 (firstname.lastname@example.org).
Conflict of Interest Disclosures: Dr DeVoe reported receiving grants from the Morris-Singer Foundation. No other disclosures were reported.
Additional Contributions: We are grateful to the Morris-Singer Foundation for the generous contribution to launch the OHSU COVID-19 Connected Care Center. We also wish to thank Drs Steve Woolf and Martin Roland for their helpful comments and guidance during the writing process. And, thank you to the entire OHSU COVID-19 Connected Care Center team for their inspiration and dedication to this important work.
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